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10 Endoscopic Nasal andParanasal Sinus Surgery
253
thinner medication such as aspirin also needs to
be withheld before surgery.
10.4.2 Informed Consent
Informed consent is also another important issue
that needs to be highlighted before we proceed
with the surgery. A good, informed consent
should include several important issues:
– Thorough explanation about the disease
– Indication for endoscopic sinus surgery
– Patient’s expectation and surgeon’s
expectation
– The procedure itself in general
– Complication of the surgery
– Post-operative care
10.4.3 Preoperative Planning/ Evaluation
Prior to the surgery, the nasal anatomy is reevaluated, and any signicant abnormalities are
noted. It is helpful to repeat the nasal endoscopy to
detect the presence of reactive nasal mucosa identied by marked congestion, sneezing, and hypersecretion during diagnostic endoscopy despite
maximum medical therapy. In this situation, if the
oedematous mucosa is not treated preoperatively,
bleeding will be increased intraoperatively.
It is essential that the patient’s CT scan be rereviewed again prior to the surgery. Preoperative
planning requires careful evaluation and conceptualization of the anatomy based upon the preoperative CT scan. This requires a systematic
review of the CT scan so as to provide not only an
understanding of the anatomy of the skull base
and the medial wall of orbit, but also the surgeon’s conceptualization of the frontal sinus
drainage pathway and the relevant anatomy of the
ethmoid pneumatization.
A checklist of anatomic landmark and variants
should be reviewed (Table 10.1), including the
presence of Onodi (sphenoethmoidal) cell and
integrity of the ethmoid. The vertical height of
the ethmoid sinus as well as the slope of the roof
of the ethmoid should also be carefully assessed.
Table 10.1 Systematic CT scan review
Yes/
No
Patient ID Is this the correct CT scan for
the patient?
Previous
surgery
Anterior
ethmoid root
Medial wall
of orbit
Posterior
ethmoid
Sphenoid
sinus
Frontal
recess/sinus
Has the patient had another
sinus surgery before?
Slope, height
Keros classication
Anterior ethmoidal artery
course
Any asymmetries
Uncinate; superior attachment
Middle turbinate; attachment
Concha bullosa
Vertical height
Dehiscence lamina papyracea
Sphenoethmoidal cells
Pneumatization
Intersinus septa
Dehiscence carotid artery
Frontal sinus drainage pathway
Frontal cell
Agger nasi
Failure to recognize a sloping pattern of skull
base will end up the surgeon entering the cranial
cavity.
When evaluating the frontal sinus for preparation of endoscopic frontal sinusotomy, the surgeon needs to conceptualize the frontal sinus
drainage pathway and the adjacent cells as they
will be encountered intraoperatively. Failure to
do so will lead to a more disastrous problem postoperatively. It may be helpful if the surgeon can
draw the drainage pathway in relation to middle
turbinate, ethmoid bulla, agger nasi, supraorbital
cells, and uncinate process. The presence of any
septal deformity is important to be addressed
also.
As the CT scan is reviewed, sphenoid skull
base, bony optic and carotid canal, size and
pneumatization pattern of the sphenoid sinus,
integrity of the bony medial wall of orbit in
case of dehiscence of lamina papyracea, and
orbital apex should also be addressed. Careful
attention is also paid to the position of anterior
ethmoidal artery and veins as these may lead to
torrential bleeding intraoperatively if not recognized prior to it.
254
R. R. Ramli et al.
It is best to view the CT scan in all planes,
coronal images, sagittal images, and axial images.
Even though most of these landmarks can be recognized on coronal images, the axial and sagittal
images can provide important supplemental anatomic perspective. For example, axial images are
best viewed for sphenoid ostium and sagittal
images of the sphenoid can easily demonstrate
Onodi cells.
MRI becomes important when there is opacication adjacent to the erosion of the skull base
or when there is tumour. Besides that, presence of
midline pulsatile mass seen during nasoendoscopy should warn the otorhinolaryngologists of
the possibility of meningoencephalocele. MR
allows the identication of meningoencephalocele and their differentiation from other tumours
or inammatory disease.
10.4.4 Preoperative Measure
toReduce Intraoperative
Bleeding
the regimes in maximal medical therapy for CRS
where the inammatory loads are still not in
control.
A systematic review and meta-analysis on the
preoperative use of local and/or systemic corticosteroids in FESS concluded that it had signicantly reduced blood loss, shortened operative
time, and improved surgical eld quality [11].
Studies are limited on the intraoperative use of
corticosteroids to reduce post-operative pain.
Post-operative corticosteroids improve postoperative endoscopic scores in CRS and recurrence rates in cases of CRSwNP.In their review
on the usage of systemic steroid, Carlton and
Chiu [12] had pointed out that there are known
risks of administration of systemic corticosteroids, and clinicians must take these into account
when evaluating an individual patient. In view of
the adverse effect of systemic steroid, Harvey
etal. (2018) suggested the usage of steroid irrigation post-operatively in the setting of diffuse or
patchy CRS disease, compared to simple nasal
spray in postsurgical patients [13].
10.4.4.1 Antibiotic
In patients with acute infection, reducing the
inammation with antibiotic will help to reduce
intraoperative bleeding. However, in a case where
there is no acute infection, the use of antibiotic
preoperatively is controversial as it is considered
as one of the regimes in maximal medical therapy
for chronic rhinosinusitis. Most surgeons do not
advocate starting antibiotic prior to the surgery.
Usage of antibiotic usually depends on intraoperative ndings of the patients [10].
10.4.4.2 Systemic Corticosteroid
The use of preoperative systemic corticosteroids
in endoscopic sinus surgery (ESS) has been a
topic of debate among otolaryngologists for
many years now. Until recently, most of the evidence to support its use in ESS was largely anecdotal and based on expert opinion. In the presence
of reactive mucosa or polyposis, the use of systemic corticosteroid preoperatively is controversial. Most of the surgeons prefer the usage of
steroid during the initial part of therapy as one of
10.4.4.3 Topical Decongestants
Usage of topical oxymetazoline has been advocated as one of the measures to reduce bleeding
intraoperatively as it has also been a common
practice among otolaryngologists. The justication is that alpha-receptor agonist can help to
reduce bleeding during surgery if used before the
operation. However, simple decongestants like
oxymetazoline are not ideal for pre-op decongestion as these are partial, mainly alpha-1 agonist,
and while they do have an effect in causing vasoconstriction on the arteriole side, they are less or
not effective on the venous side. Furthermore,
they are competitive agonists at the same receptors that adrenaline works at. So why use these
partial agonists when they can only compete with
adrenaline and diminish the effects of adrenaline,
which is going to be part of our topical preparation and inltration intraoperatively?
10.4.4.4 Adrenaline
It stimulates both alpha-1 and -2 receptors.
Furthermore, the degree of vasoconstriction is
10 Endoscopic Nasal andParanasal Sinus Surgery
255
dose dependent. Adrenaline can accurately
achieve optimal local vasoconstriction while
minimizing the systemic effects. Topical vasoconstriction of adrenaline via gauze or cotton
pledges with a concentration of 1:1000 in children or 1:2000in at-risk patients has been demonstrated to be safe [14].
10.4.4.5 Moett’s Solution
In our centre, we advocate the use of Moffett’s
solution as topical decongestion and local anaesthetic prior to endoscopic sinus surgery. It is a
combination of cocaine, adrenaline, bicarbonate,
and 0.9% sodium chloride, which was rst
described by Major A.J. Moffett of the Royal
Army Medical Corps in 1941 [15]. The combination of cocaine and adrenaline synergistically
acts on both alpha-1 and alpha-2 adrenoreceptors
in nasal vasculature. When applied topically to
the nasal mucosa, it produces profound vasoconstriction and anaesthesia, reducing blood loss and
improving visualization in the operative eld for
sinonasal surgery [16]. The solution consists of a
mixture of 2 mL of 10% cocaine solution
(200mg), 1mL of 1:1000 adrenaline, 2mL of
sodium bicarbonate, and 5mL of 0.9% sodium
chloride solution, 10 mL in total with 5 mL
applied to each side.
10.4.5 Anaesthesia
Endoscopic sinus surgery can be performed satisfactorily under either local anaesthesia with sedation or general anaesthesia. With the advancement
in anaesthetic drugs, less blood loss was encountered in endoscopic sinus surgery. Hypotensive
anaesthesia has been used to reduce bleeding
intraoperatively. The mean arterial pressure
(MAP) is aimed to be in between 50 and
70mmHg. To have a good surgical eld in endoscopic sinus surgery, it usually relies on good
vasoconstriction and good clotting mechanism.
This is when the term hypotensive anaesthesia is
coined. Neither vessel ligation nor extensive diathermy is needed once a clear surgical eld is
achieved.
Surgical eld improves with bradycardia
anaesthesia [17]. With this nding, bradycardia
anaesthesia is achieved by using total intravenous
anaesthesia (TIVA) with either propofol or remifentanil. Meta-analysis study on total intravenous
anaesthesia (TIVA) vs. inhalational anaesthesia
indicates that TIVA has the potential to confer
superior surgical eld visibility and reduce intraoperative blood loss compared to inhalational
anaesthesia in ESS [18]. TIVA has been demonstrated to be associated with less blood from prior
inhalational agents [19].
10.4.6 Positioning ofPatient
The reverse Trendelenburg position (RTP), a
head-up, feet-down tilt varying from 10° to 30°,
is also commonly used during ESS [20]. The RTP
reduces venous return and cardiac output by
retaining blood in the lower parts of the body.
The 15° RTP improves the endoscopic eld of
view and reduces blood loss during ESS [21].
10.4.7 Image-Guided System (IGS)
Image-guided systems (IGS) have gained widespread use in endoscopic sinus surgery (ESS) and
have been thoroughly analysed. The use of IGS
in ESS and anterior skull base surgery is predicated on the notion that its ability to aid in anatomic identication during surgery will lead to
fewer complications and improved surgical outcomes. Based on the best available evidence in
the literature, the use of IGS has not clearly been
shown to decrease surgical complications or
improve surgical outcomes [22].
Level 2A evidence from systematic reviews
suggests that in certain cases IGS may be associated with decreased major and total surgical complications, though the potential for bias and
confounding exists in these conclusions. The
choice to use IGS in any endoscopic procedure
remains best determined by the operating surgeon
based on factors including case complexity and
surgeon comfort [23].
256
R. R. Ramli et al.
10.5 Operative Techniques
10.5.1 Endoscopic Sinus Surgery
After topical decongestion with Moffett’s solution, by using a 0° Hopkins telescope, a local
inltration with Scandonest 2% (adrenaline
0.001% and mepivacaine HCl 2%) is placed at
the body and axilla of the middle turbinates, and
lateral wall of the nasal cavity as shown in
Fig.10.4. Then, the middle turbinate is ‘relaxed’
by gently medializing it with utmost precaution
to avoid injury to the lateral lamella of the cribriform plate (Fig.10.5). In a case of a bulky concha
Fig. 10.4 Positioning
of patient in reverse
Trendelenburg position
bullosa or paradoxical middle turbinate, surgical
access is widened by resection of the lateral part
of the middle turbinate. Again, care is to be taken
to have a clean sharp cutting edge and avoid
unnecessary mucosal injury surrounding this area
to prevent synechia formation (Fig.10.6).
10.5.1.1 Uncinectomy
The free edge of the uncinate process is identied
and probed in an upward-downward direction
and teased out anteromedially. There are two
approaches for uncinectomy: antegrade and retrograde approach. We prefer to use a retrograde
approach as the antegrade approach may increase
Fig. 10.5 Injection sites for the local anaesthesia (marked
with asterisks *). Axilla and body of left middle turbinate
(MT), lateral wall of nasal cavity (LW). Septum, S
Fig. 10.6 Relaxation of the left middle turbinate (MT)
by gently medializing it from inferoposterior to inferomedial direction. Septum (S) and Lateral wall (LW) of the
nasal cavity
10 Endoscopic Nasal andParanasal Sinus Surgery
257
a
Fig. 10.7 Left uncinate process (UP) was removed by using (a) a backbiting forceps and (b) an upturned through-
cutting Blakesley forceps. Septum, S; middle turbinate, MT; and lateral wall of nasal cavity, LW
b
the risk of penetrating the lacrimal sac or breaching lamina papyracea, especially in the case of an
atelectatic uncinate process, hence injuring the
orbit. By using a retrograde approach, both vertical and horizontal parts of the uncinate process
are removed by cutting with a backbiting forceps
at the middle of the vertical component of the
uncinate process, whereby usually 2–3 bites are
needed (Fig.10.7). Then the rest of the uncinate
process can be removed with the backbiter forceps angled 45° cutting in upwards direction or
using an upturned through-cutting Blakesley forceps or a microdebrider to trim it.
10.5.1.2 Middle Meatal Antrostomy (MMA)
The true maxillary sinus ostium is usually visualized after uncinectomy. Sometimes, mucus or
mucopus discharge with some debris can be seen
owing out of the sinus ostium when the medial
wall of the maxillary sinus is pressed. It can also
be identied by using a right-angled ball-tipped
probe, curved curette, or sinus suction tube. Then
the posterior fontanelle is removed with a straight
Blakesley forceps and a backbiting forceps as
shown in Fig.10.8. The MMA can also be performed by using a microdebrider. If a Haller cell
is encountered, the inferomedial part of the Haller
Fig. 10.8 Left middle meatal antrostomy performed by
removing the posterior fontanelle (PF), using a straight
Blakesley forceps in a backward direction (along the yellow asterisks) and a backbiting forceps in a forward direction (along the green asterisks). True left maxillary sinus
ostium (SO)
cell is removed rst and the dissection continued
until the surgeon can engage where the posterior
wall and roof of the maxillary sinus are. Careful
dissection is necessary to avoid injury to the
orbit. Palpation of the eye globe helps to guide
258
Fig. 10.9 Left bulla ethmoidalis (BE) was opened with a
straight curette at the inferomedial part of the bulla. MT
middle turbinate, LP lamina papyracea
the surgeon if the lamina papyracea has been
breached.
10.5.1.3 Ethmoidal Bullectomy
The bulla ethmoidalis is identied, and a straight
curette is used to open the inferomedial part of
the bulla as seen in Fig.10.9. Then the rest of the
bulla is removed by using a straight throughcutting Blakesley forceps and a microdebrider. In
a case of anterior ESS or mini-ESS, uncinectomy
and opening of the anterior face of the bulla are
done with retention of 3–4mm mucosa from the
edge of the anterior and inferior part of the bulla
[5]. If proceeding to posterior ethmoidectomy, all
the anterior wall of the bulla is removed to gain
better access.
10.5.1.4 Posterior Ethmoidectomy
After uncapping the bulla, the posterior ethmoid
sinus region is entered by opening up the basal
lamella of the middle turbinate with a straight
curette, ball probe, or straight Blakesley forceps
at its inferior and medial part, at the same level
with the roof of the maxillary sinus. Then the
posterior ethmoid air cells are removed with a
straight through-cutting Blakesley forceps, a
straight curette, or a microdebrider (Fig.10.10).
R. R. Ramli et al.
Fig. 10.10 After penetrating the basal lamella of right
middle turbinate (MT), posterior ethmoidectomy was performed by using a microdebrider. PEAC posterior eth-
moid air cells. The roof of right maxillary sinus is shown
by the yellow arrow
Keep in mind that the base of the skull runs in a
downward sloping fashion as it goes more posteriorly. The base of the skull is also recognized by
its pale ivory-coloured mucosa.
10.5.1.5 Sphenoidotomy
During the posterior ethmoidectomy, landmarks
of the sphenoid sinus ostium are identied, i.e.
the superior turbinate, the roof of maxillary sinus,
and the posterior choana, which have been discussed earlier in the ‘surgical anatomy section’.
The sphenoid sinus ostium can be identied by
either transnasal or transethmoid approach. In a
transethmoid approach, once the basal lamella is
breached, the superior turbinate is identied. The
sphenoid ostium is more clearly visualized when
one-third up to half of the inferior part of the
superior turbinate is removed with a straight
through-cutting Blakesley forceps or microdebrider (Fig.10.11). It is most of the time medial
to the superior turbinate. The ostium can be
enlarged adequately by removing part of the
anterior face of the sphenoid sinus with a Kerrison
punch or microdebrider. The maximum border
for removal of the anterior face of the sphenoid
will be the base of the skull superiorly, the oor
10 Endoscopic Nasal andParanasal Sinus Surgery
259
Fig. 10.11 Right sphenoid sinus ostium is shown by the
yellow arrow. The right superior turbinate (ST) was
trimmed with a microdebrider. Posterior nasal septum, PS
and right middle turbinate, MT
of the sphenoid sinus inferiorly, the posterior part
of the nasal septum medially, and the lamina papyracea laterally. Important neurovascular structures such as internal carotid artery and optic
nerve should be kept in mind during the dissection, especially when Onodi cell is encountered.
The optic nerve may lie freely within the Onodi
cell; hence, extra precaution is needed.
10.5.1.6 Frontal Sinusotomy
The frontal sinus is usually addressed last due to
its complex anatomy, and that bleeding from the
frontal sinus work may drip down obscuring the
surgical eld when working more posteriorly. A
45° or 70° Hopkins telescope can be used for a
better visualization during the dissection. The
frontal recess can be identied by probing with a
frontal seeker or sinus suction tube (Fig.10.12).
The cells obstructing the frontal sinus outow
should be studied thoroughly preoperatively and
removed carefully. A navigation system with a
registered frontal probe will be helpful in this frontal sinus work. The obstructed cells can be removed
using a curved curette, Stammberger upward-cutting forceps, or frontal giraffe forceps to widen the
frontal recess. Endonasal frontal sinusotomy can
be classied into Draf I–III (Table10.2).
Fig. 10.12 A long curved sinus suction tube was inserted
into the right frontal recess as shown by the yellow arrow.
Right polypoidal middle turbinate, MT, and septum, S
Table 10.2 Types of frontal sinusotomy according to
Draf [24]
Type Extent of surgery
I Anterior ethmoidectomy with drainage of the
frontal recess without touching the frontal
sinus outow tract
IIa Removal of ethmoid cells protruding into the
frontal sinus, creating an opening between the
middle turbinate medially and lamina
papyracea laterally
IIb Removal of the oor of frontal sinus between
the nasal septum medially and lamina
papyracea laterally
III Bilateral Draf type II drainage with removal of
the superior part of nasal septum and lower
part of intersinus septum
The Draf type I is achieved by clearing the
anterior ethmoid cells without manipulation of
frontal sinus outow. The Draf IIa–b are usually
performed in case of mucocoele or complication
of acute rhinosinusitis. Endoscopic modied
Lothrop procedure or Draf III is commonly
reserved for revision cases or resection of anterior skull base tumours [24].
Endoscopic sinus surgery has come a long
way since its maiden application in the late
1800s. It was rst introduced as a procedure to be
260
R. R. Ramli et al.
applied to organs ‘down-south’ examining the
urinary tract and the bladder. That was the rst
time the word endoscope was used. Nowadays,
endoscopic sinus surgery (ESS) is almost synonymous with rhinology as more surgeons are
adapting well with ESS in their practice. The
technique in ESS is ne-tuned as time progresses,
where surgeons learn and modify steps in ESS to
improve the outcome. The number of otorhinolaryngology head and neck surgery (ORL-HNS)
surgeons has increased as well as the number of
ESS procedures. With that said, one must consider the learning curve of these surgeons in
expecting the possibility of ESS complications.
Like all surgical procedures, the risk and possibility of complications will have to be
addressed. Besides the importance of explaining
before surgery the indications and the basic steps
of the ESS to the patient, the risk and complications must also be explained in detail so that
patients will understand and be aware of all the
issues before the surgery. Equally important is
that the surgeon himself/herself must understand
the risk and complication thoroughly if not more
than the patient must as well as how to avoid and
solve if one encounters such complications.
Complications in ESS can be categorized into
minor and major complications, by location, procedure, and timing of the procedure, i.e. intraoperative vs. post-operative. Recognising and
anticipating complications is as important as preventing and managing them. Below are the complications and suggestions on how to manage
them.
10.6 Intraoperative Complication
Intraoperative complications during ESS can be
further divided into intranasal, intraorbital, and
intracranial.
10.6.1 Intranasal Complications
10.6.1.1 Haemorrhage fromMucosa
The nasal airway is a vascular area, with its
main supply coming from two main arteries,
which are the internal and the external carotid
arteries (ICA and ECA). The ICA branches into
the ophthalmic artery, which then supplies the
anterior and the posterior ethmoid arteries. The
branches of ECA, i.e. the facial and the internal
maxillary arteries, supply the rest of the nasal
airway.
Bleeding from the mucosal surface of the
nasal airway while doing ESS is sometimes
unavoidable but only to be considered cumbersome when it hinders the view in ESS.According
to Rem etal. (2011), about 0.8% and 5% of the
minor bleeding were perioperative and postoperative haemorrhages, respectively [25]. It
can be localized or diffuse. The bleeding can be
procedure, surgical, or patient related. It usually occurs in circumstances such as the
following:
1. Multiple or inappropriate instruments used in
ESS which when in contact with the surrounding structure will cause injury and
bleeding.
2. Inamed mucosa in active diseases such as
chronic rhinosinusitis with or without nasal
polyposis: Therefore, the pre- and intraoperative preparation is important to avoid diffuse
mucosal bleeding [26, 27].
Statistics
1. Epistaxis requiring intervention is 0.6–1.6%,
whereas major haemorrhage that requires
transfusion is 0.76% [28, 29].
2. Endoscopic sinus surgery is affected by diffuse
bleeding in about 5% of cases, and about 1.4% of
the procedures are cancelled [27, 30].
3. Two percentage of bleeding complications occur
during and post operation, and only 0.2% of cases
need transfusion [31, 32].
4. Post-operative haemorrhage following
endoscopic nasal sinus surgery occurs in 2.7% of
patients [33].
Prevention
Preoperative measures
1. Preoperative systemic steroid (e.g. 30–60mg/day
prednisone for 7–14days before surgery) can
reduce bleeding, therefore reducing the duration
of surgery.
2. Position the patient in a reverse Trendelenburg,
i.e. lifting the head and the upper part of the
patient’s body for about 10–20° can be successful
in reducing intraoperative bleeding [34, 35].
10 Endoscopic Nasal andParanasal Sinus Surgery
261
Prevention
Intraoperative measures
1. Appropriate instruments for each procedure, i.e.
sharp through-cutting forceps for thin bony
removal and sharp soft-tissue cutting (Blakesley
forceps) to remove or mobilize polyps or tissue.
Polyps or tissue should be cut not pulled when
using the tissue-cutting forceps, to avoid
excessive mucosal bleed [36].
2. When inserting a sharp instrument, it is advisable
that the scope follows the instrument. The instrument
should be in front of the scope so that you can see
the instrument as it is manoeuvred through the
nasalcavity. This way you avoid injury to the
surrounding mucosa and thus unnecessary bleeding.
3. Study has shown that local injection of
vasoconstrictors, i.e. epinephrine, has no
signicant benet over topical vasoconstrictors
[37]. However, Fokkens etal. reported that
preoperative injections of local anaesthetic
(1:80,000 adrenaline) and vasoconstrictor into the
greater palatine canal effectively reduce
intraoperative bleeding in ESS [34]. Topical
vasoconstrictors suggested include the following:
(a) 1:2000 adrenaline has been shown to have better
haemostatic effect over much lower
concentrations [34]. The risk of optic nerve
damage and blindness after the application of
local adrenaline has been reported in 0.05% [38].
(b) Oxymetazoline 0.05% or epinephrine 1:2000
may be used for children [39].
4. EPOS 2020 concluded that there is a level I
evidence that the usage of propofol in achieving
hypotension improved surgical eld, but it is less
superior when compared to the usage of alpha-2adrenergic agonists. Fokkens etal. show that total
intravenous anaesthetic (TIVA) is more superior to
inhalation anaesthetic (IA) in reducing blood loss,
hence improving the surgical eld [34]. The
recommended pulse rate is 60min−1 [40].
5. Using warm saline of up to 50°C to irrigate the
surgical area has signicantly reduced blood loss
and duration of surgery, therefore enhancing the
visibility of the surgical site and improving the
outcome of functional endoscopic sinus surgery
and septorhinoplasty [41]. Irrigating with hot
saline improves the view of the surgical eld in
FESS after 2h of operating time [42]. Solares
etal. showed that rinsing the surgical eld with
40°C water is also helpful [26].
6. The use of tranexamic acid: Kim etal. showed
that the operative time and the intraoperative time
were statistically lower in the tranexamic group,
and it shows no signicant effect on thrombotic
events compared to placebo [43]. Similar ndings
by El Shah etal. were shown when intravenous
tranexamic acid was given to the patient [44]. The
suggested dosage is IV tranexamic acid 10mg/kg
diluted in 100mL saline administered during
10-min infusion [44, 45].
10.6.1.2 Arterial Injury
The arteries that are commonly dreaded in ESS
are the sphenoidal artery and its branches, the
anterior ethmoidal artery, and nally the internal
carotid artery.
10.6.1.2.1 Sphenopalatine Artery
The commonly injured artery would be the sphenoidal artery at its branches. It emerges from the
sphenopalatine foramen, which is identied by
elevating a mucoperiosteal ap and identifying
the crista ethmoidalis, at the posterior aspect of
the middle meatus within the superior meatus
[46]. It branches into posterior septal branch (PS)
supplying the anterior wall of the sphenoid sinus
and the septum, and to the lateral wall via posterior lateral nasal branch (PLN) [47] (Figs.10.13
and 10.14, Table10.3).
Prevention
• Identify the bleeding source and secure it via
cauterization and surgical clip. Rarely, extension is
done laterally at the posterior wall of the maxillary
sinus if the SPA is retracted laterally.
10.6.1.2.2 Anterior Ethmoidal Artery (AEA)
Besides causing signicant bleeding during surgery, a complete transection of the AEA may
result in retraction of the lateral stump end into
the orbit causing orbital haematoma, which is a
major complication.
The anterior ethmoidal artery (AEA) is supplied
by the ophthalmic artery, which is the branch of the
Fig. 10.13 Illustration showing the posterior lateral
nasal wall and the branches of the sphenopalatine artery
(SPA). PLN posterior lateral nasal branch
262
ac
R. R. Ramli et al.
b
Fig. 10.14 Bipolar cauterization of a bleeding sphenoid artery (SPA). (a) Bleeding (sputter) from sphenoid artery. (b)
Bipolar cauterization used to stop the SPA bleed. (c) Charred area post cauterization
Table 10.3
branches
Branches Procedure
PLN Bleeding due to aggressive
PS In transnasal sphenoidal approach, i.e.
Branches of
SPA at the
SPF
internal carotid artery. From the orbit, it traverses
medially through the lamina papyracea and enters
the anterior ethmoid sinus. The artery may be iden-
Procedures that may injure the SPA and its
debridement of the posterior Fontanelle
during posterior extension of the
medial maxillary antrostomy
pituitary surgery. Widening of the
sphenoid ostium inferiorly will cause
bleeding from the PS branch of the SPA
Several ostia may be present at the SPF
13% [48]. Bleeding may occur while
locating the SPF due to the branches
that emerge from extra ostia
In the majority of cases, the AEA can be adequately cauterized using endoscopic bipolar
instruments, thus avoiding transmitting the electrical current to the skull base and orbit.
Prevention
1. Preoperative imaging
Identication of the position of the AEA through
imaging is important to determine if AEA is
‘hanging’ in the ethmoid roof or within the bony
mesentery. AEA can be best seen as a pinch or
‘nipple’ between the medial rectus and superior
oblique muscles in the coronal view of the
computed tomography (CT) scan (Fig.10.16).
2. Instrument precaution
Always have in view whatever you want to cut.
Usage of powered instrument, i.e. microdebrider,
must be with extra precaution. Once unsure, gentle
usage of upturned tissue-cutting forceps is
advisable.
tied endoscopically running along the skull base,
i.e. the roof of the ethmoidal sinuses, just posterior
to the anterior face of the bulla ethmoidalis. It then
pierces through the lateral wall of the olfactory
recess. In-between its lateral entrance and medial
exit is the area of vulnerability for AEA.
Floreani et al., in their cadaveric studies,
showed that 20% of AEA that runs in a bony
mesentery was able to be clipped effectively [49].
Another important anatomy feature of AEA is
that the blood ow through the anterior ethmoid
artery comes from a posterolateral to an anteromedial direction, at 60° angle [35] (Fig.10.15).
10.6.1.2.3 Posterior Ethmoidal Artery (PEA)
The posterior ethmoidal artery is a branch of the
ophthalmic artery and runs symmetrical, and it is
much smaller than the AEA.The bone overlying
it, in most cases, is approximately 60% dehiscence. PEA is most commonly injured during
sphenoid sinus surgery or during posterior ethmoidectomy [40]. If bleeding occurs due to
injury to the PEA, a bipolar cautery is a preferable measure to control the bleeding, thus avoiding transmitting of the electrical current to the